Chapter 16
Management of Pain and
Anxiety
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1
Anesthetic Emergencies
• Studies show that more than half of all
dental emergencies occur during or after
giving anesthetic
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2
Techniques to Manage Pain
• Sedation
– Oral sedation
– Nitrous oxide gas
• Topical anesthetic
• Local anesthetic
• General anesthetic
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3
Sedation
• Used to relax the patient before anesthetic
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4
Types of Sedation
• Premedication
– Liquid
– Pill
• Nitrous oxide gas
• Used in conjunction with local anesthetic
• Patient requires supervision
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5
Nitrous Oxide
• Anesthetic agent
• Patient remains conscious
• Raises the pain threshold
• Used in conjunction with local
anesthetic
• Patient is more receptive to treatment
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6
Indications for Nitrous Oxide
•
•
•
•
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Heart patients
Patients that gag easily
Fearful or stressed patients
Longer appointments
Patients able to breathe through nose
easily
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Baseline
• The ratio that is most effective on patient
• Patient should be:
– Cooperative
– Conscious
– Relaxed
• Record baseline on patient’s chart
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Topical Anesthetic
• Temporarily numbs nerve endings
• Application
– Before local anesthetic injection
– Reduces gagging sensation
• Impressions
• Radiograph
• Types
– Ointments/gels
– Liquids/mouth rinses
– Sprays
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9
Placing Topical Anesthetic
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Topical Anesthetic May Cause
Reaction
• Topical 5% to 10% anesthetic solution
• Local consists of 2% anesthetic solution
• Signs include:
– Talkative
– Apprehensive
– Excited
– Increased pulse and blood pressure
– Patient becomes sleepy afterward
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11
Local Anesthetic
•
•
•
•
Used routinely for pain management
Intraoral injection administered
Produces a pain-free area
Sensory impulses are temporarily blocked
from:
– Pain
– Touch
– Thermal
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12
Determining Factors for Amount of
Anesthetic Administered
•
•
•
•
Age
Weight
Physical condition
Liver function
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13
Overdose of Anesthetic
•
•
•
•
•
•
Drop in blood pressure
Nausea and vomiting
Pallor
Convulsions
Muscular twitching
Apprehension
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14
Possible Complications of
Anesthetic
• Paresthesia: temporary numbness
– Nerve sheath damage during injection
– Hemorrhage: creating pressure on nerve
– Contamination of anesthetic
• Patient may bite tongue, cheeks, lips
• Condition is rarely permanent
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15
Two Types of Anesthetic
Solutions
• Amides
– Lidocaine
• Ester
– Benzocaine
• Patient may be sensitive to one
and not the other
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16
Properties of Vasoconstrictors
• Decreases the risk of a toxic reaction by
slowing the absorption of anesthetic into
bloodstream
• Constricts the blood vessel, which in turn
controls bleeding
• Prolongs the duration of anesthetic
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17
Epinephrine
• Added to local anesthetics as a
vasoconstrictor
• Not used on heart patients
• Ratio of vasoconstrictor to anesthetic
– 1:50,000, 1:100,000, 1:200,000
• EXAMPLE: 1 part epinephrine to 50,000 parts
anesthetic
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18
Anesthetic Label
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19
How Nerves Innervate the
Tooth
Pulp horns
Enamel
Pulp chamber
Pulp
Dentin
Pulp canal
Cementum
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Anatomy Review of Maxillary
Arch
Incisive foramen
Palatine process
of the maxilla
Median palatine
suture
Transverse
palatine suture
Maxillary
tuberosity
Horizontal plate
of palatine bone
Greater palatine foramen
Lesser palatine foramina
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21
Maxillary Arch Injections
Nasopalatine nerve block
Anterior superior
alveolar nerve block
(infraobital nerve block)
Middle superior
alveolar nerve
block
Posterior superior
alveolar nerve
block
Greater palatine nerve block
(anterior palatine nerve block)
Maxillary nerve block
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22
Anatomy Review of Mandibular
Arch
Condyle
Mandibular
(sigmoid) notch
Coronoid
process
Ramus
Retromolar
area
Mandibular angle
Mylohyoid line
External oblique ridge
Submandibular
fossa
Border of the mandible
Mental foramen
Mental protuberance
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23
Anatomy Review of Mandibular
Arch
Coronoid
process
Internal
oblique ridge
Sublingual fossa
Condyle
Mandibular
foramen
Mylohyoid
groove
Submandibular
fossa
Genial tubercles
Lingual foramen
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24
Mandibular Arch Injections
Lingual nerve block
Buccal nerve block
Incisive
nerve block
Inferior alveolar nerve block
(mandibular nerve block)
Mental nerve block
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Types of Injections
• Local infiltration
– Surrounding tissue or one tooth
• Field blocks
– One or two teeth
• Nerve blocks
– Entire quadrant
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Local Infiltration
• Injected into tissues at the end of the
nerve branch
• 1 to 2 minutes until effective
• Used on procedures that involve soft
tissue
– Biopsy, gingivectomy, prophylaxis
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27
Field Block
• Used on procedures that involve the teeth
and/or bone
– Restorative
• Injection site is near the apex of tooth
• 2 to 3 minutes until anesthetic is effective
• Commonly used on maxillary arch
– Absorbs well due to cancellous bone
• Used in anterior regions of both arches
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Nerve Block
• Injected near a main nerve trunk
• 4 to 5 minutes until effective
• Injected near foramen sites
– Incisive
– Mandibular
– Mental
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29
Anesthetic Setup
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Syringe
• Aspirating syringe allows operator to
verify that they have not penetrated a
blood vessel.
• Harpoon of syringe is retracted; if blood
appears in syringe then needle is
repositioned.
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31
Aspirating Syringe
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The Needle
• Short: 1 inch
– Used in infiltrations and field blocks
– Periodontal ligament injections
• Long: 1-5/8 inch
– Used for nerve blocks
• Maxillary and mandibular
• Reaches posterior areas
– For areas that require penetration of thicker
tissue
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33
Components of a Needle
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34
Needle Gauge
• Sizes
– 25 gauge
– 27 gauge
– 30 gauge
• The smaller the gauge the larger the
diameter of the needle
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35
Anesthetic Cartridge
Components
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36
Retracting Harpoon
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37
Loading Cartridge into Syringe
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38
Engaging Harpoon
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39
Placement of Needle into
Syringe
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40
Passing the Syringe
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41
Disassembling the Syringe
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42
Intraosseous Anesthesia
• Cancellous bone injected
• Requires special system
• Anesthetizes the following:
– Bone
– Soft tissue
– Root
– Teeth
– Single or multiple teeth
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43
Periodontal Ligament Injection
•
•
•
•
Often used with other types of injections
Outcome: pulpal anesthesia
Diagnosing abscessed teeth
Technique
– The needle is inserted into the gingival sulcus
of the tooth
– Requires special pressure syringes
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44
Periodontal Ligament Injection
System
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45
Intrapulpal Injection
• Injection delivered directly into nerve
chamber
• Used when unable to numb patient by
traditional methods
• Procedures
– Root canal therapy
– Severe abscess
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46
General Anesthetic
• Reserved for extensive restorative
procedures or surgeries
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47
General Anesthetic
•
•
•
•
Patient becomes unconscious
Nitrous oxide and intravenous (IV) drugs
Patient must be monitored
Used during
–
–
–
–
Extensive treatment
Surgeries
Uncooperative patients
Children
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Contraindications
• Blocked nasal passage
• Pregnancy
• Emotional instability
– Alters perception of reality
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•
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Emphysema
Multiple sclerosis
Street drug users
Immune-compromised patients
– Bone marrow suppression
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